The cost-efficacy of a healthy food box for managing hypertension within a native American population: a group randomized controlled trial.

BACKGROUND: Dietary interventions are used for the treatment of hypertension. We evaluated the cost-efficacy of delivering boxes of healthy, culturally tailored foods and checks that can only be spent on produce in a Native American population. METHODS: We conducted a group randomized controlled trial from 2018 to 2020 with N = 2 treatment counties and N = 2 control counties and a total of N = 160 Native American adults with baseline stage 1 or stage 2 hypertension. Participants in the intervention group received monthly boxes of food that adheres to the Dietary Approaches to Stop Hypertension diet as well as checks that could only be spent on produce for 6 months. We measured blood pressure and quality of life at baseline and at a 6-month follow-up in both intervention and control groups. We used ordered logistic regression to estimate the effect of treatment on probability of blood pressure improvements. We then conducted a cost-efficacy analysis. RESULTS: We found that treatment was effective in reducing blood pressure in women with stage 1 hypertension at baseline. Based on this finding, we also estimate that this intervention satisfies normative cost-effectiveness thresholds, even when lifetime treatment is needed to preserve the impact, so long as treatment is only continued in those who respond to treatment. CONCLUSIONS: Direct delivery of healthy foods and checks that can only be spent on produce are a potentially cost-effective intervention for the management of hypertension among Native American women with stage 1 hypertension. Further research is needed to understand why we found an impact only for this group.

The Cost-Efficacy of a Healthy Food Box for Managing Hypertension Within a Native American Population: The Chickasaw Healthy Eating Environment Research Study.

Background Dietary interventions are used for the treatment of hypertension. We evaluated the cost-efficacy of delivering boxes of healthy, culturally tailored foods and checks that can only be spent on produce in a Native American population. Methods We conducted a group randomized controlled trial from 2018-2020 with N = 2 treatment counties and N = 2 control counties and a total of N = 160 Native American adults with baseline stage 1 or stage 2 hypertension. Participants in the intervention group received monthly boxes of food that adheres to the Dietary Approaches to Stop Hypertension diet as well as checks that could only be spent on produce for 6 months. We measured blood pressure and quality of life at baseline and at a 6-month follow-up in both intervention and control groups. We used ordered logistic regression to estimate the effect of treatment on probability of blood pressure improvements. We then conducted a cost-efficacy analysis. Results We found that treatment was effective in women with stage 1 hypertension at baseline. Based on this finding, we also estimate that this intervention satisfies normative cost-effectiveness thresholds, even when lifetime treatment is needed to preserve the impact, so long as treatment is only continued in those who respond to treatment. Conclusions Direct delivery of healthy foods and checks that can only be spent on produce are a potentially cost-effective intervention for the management of hypertension among Native American women with stage 1 hypertension. Further research is needed to understand why we found an impact only for this group.

The use of patient navigation to transition detoxification patients to substance use treatment in the Alaska Interior.

Objectives: Detoxification clinics manage acute intoxication and withdrawal from alcohol and other drugs. At discharge, patients are referred to treatment, yet many are readmitted to detoxification, creating a "revolving door" of discharges and admissions. This pattern disproportionately affects some groups such as Alaska Native and American Indian (AN/AI) people. The primary goals of this study are to: 1) test the effectiveness of a patient navigation intervention to increase rates of transition to alcohol treatment following detoxification, and 2) prevent readmission to detoxification within 12-months. The secondary goal is a cost-effectiveness and cost-benefit evaluation of patient navigation. Study design: This randomized controlled comparative effectiveness trial plans to recruit 440 patients (∼70% AN/AI) admitted to alcohol detoxification. We collaborated with Fairbanks Native Association (FNA) to select an appropriate intervention, control condition, and other study-related decisions. Here, we describe intervention development, study design, challenges encountered during implementation, and collaborative processes to identify solutions. Methods: Participants are equally randomized to the control (one motivational interviewing session) or intervention (one motivational interviewing session plus up to four weeks of patient navigation). The primary outcomes are successful transition to alcohol treatment within 30-days after discharge and detoxification readmission within 12-months. The secondary outcome is health-related quality of life. Conclusion: Patient navigation is successful in other settings and for other health conditions. It may assist in overcoming barriers to successful transition to substance use treatment and may augment interventions, such as motivational interviewing, that are less resource-intensive but may not be optimally effective by themselves. ClinicalTrialsgov Identifier: NCT03737864.

Leaving the labor market: Exit routes, personality traits and well-being.

In this paper we examine the buffering effects of personality traits when people leave their work in later life. Using large-scale panel data for the UK, we show that depending on the exit route and satisfaction related to overall life and the domains of income and leisure, different personality traits act as moderators. Besides augmenting leisure satisfaction for those who hit mandatory retirement, conscientiousness augments life satisfaction for those becoming unemployed. On the contrary, extraversion mitigates satisfaction with life, income, and leisure for those who retire early. This may be an indication that extraverted individuals who tend to be sociable and outgoing may suffer when losing social relationships from their work. At the same time, extraversion may be helpful in augmenting leisure satisfaction for those who stop working for reasons related to ill health or family care. Neuroticism augments income satisfaction for those who become unemployed, which may reflect that people high in neuroticism had a lower "baseline level" of income satisfaction relative to typical individuals so they were not affected as much. Finally, agreeableness mitigates life and leisure satisfaction for those hitting mandatory retirement, as is also the case with openness in terms of income satisfaction.

Choice of home blood pressure monitoring device: the role of device characteristics among Alaska Native and American Indian peoples.

BACKGROUND: Home blood pressure monitoring (HBPM) is an effective tool in treatment and long-term management of hypertension. HBPM incorporates more data points to help patients and providers with diagnosis and management. The characteristics of HBPM devices matter to patients, but the relative importance of the characteristics in choosing a device remains unclear. METHODS: We used data from a randomized cross-over pilot study with 100 Alaska Native and American Indian (ANAI) people with hypertension to assess the choice of a wrist or arm HBPM device. We use a random utility framework to evaluate the relationship between stated likely use, perceived accuracy, ease of use, comfort, and participant characteristics with choice of device. Additional analyses examined willingness to change to a more accurate device. RESULTS: Participants ranked the wrist device higher compared to the arm on a 5-point Likert scale for likely use, ease of use, and comfort (0.3, 0.5, 0.8 percentage points, respectively). Most participants (66%) choose the wrist device. Likely use (wrist and arm devices) was related to the probability of choosing the wrist (0.7 and - 1.4 percentage points, respectively). Independent of characteristics, 75% of participants would be willing to use the more accurate device. Ease of use (wrist device) and comfort (arm device) were associated with the probability of changing to a more accurate device (- 1.1 and 0.5 percentage points, respectively). CONCLUSION: Usability, including comfort, ease, and likely use, appeared to discount the relative importance of perceived accuracy in the device choice. Our results contribute evidence that ANAI populations value accurate HBPM, but that the devices should also be easy to use and comfortable to facilitate long-term management.

GEOGRAPHICAL ACCESS TO RECREATIONAL MARIJUANA.

We investigate whether adult marijuana use in Washington responds to increased local access as measured by drive time to the nearest legal marijuana retailer as well as measures of retail density. Using survey data from the Behavioral Risk Factor Surveillance System, we find that as retailers open closer to where they live, more individuals use marijuana and more frequently. These effects are concentrated among young adults (ages 18-26), women, and rural residents. Controlling for distance to the nearest retailer, we find that whether retail density affects marijuana use depends on how it is measured.

Home Blood Pressure Monitoring Devices: Device Performance in an Alaska Native and American Indian Population.

Objectives: Home blood pressure monitoring (HBPM) is an important component of blood pressure (BP) management. We assessed performance of two HBPM devices among Alaska Native and American Indian people (ANAIs). Methods: We measured BP using Omron BP786 arm cuff, Omron BP654 wrist cuff, and Baum aneroid sphygmomanometer in 100 ANAIs. Performance was assessed with intraclass correlation, paired t-tests, and calibration models. Results: Compared to sphygmomanometer, average BP was higher for wrist cuff (systolic = 4.8 mmHg and diastolic = 3.6 mmHg) and varied for arm cuff (systolic = -1.5 mmHg and diastolic = 2.5 mmHg). Calibration increased performance from grade B to A for arm cuff and from D to B for wrist cuff. Calibration increased false negatives and decreased false positives. Discussion: The arm HBPM device is more accurate than the wrist cuff among ANAIs with hypertension. Most patients are willing to use the arm cuff when accuracy is discussed.

A culturally tailored intervention to reduce risk of alcohol-exposed pregnancies in American Indian communities: Rationale, design, and methods.

INTRODUCTION: Prenatal exposure to alcohol can cause lifelong physical and cognitive challenges in the form of fetal alcohol syndrome and other fetal alcohol spectrum disorders (FASDs). The prevention of prenatal alcohol exposure is thus a public health priority - and one that should account for the particular needs of subpopulations, including in American Indian/Alaska Native (AI/AN) communities. Prior to conception, alcohol-exposed pregnancy prevention is accomplished by encouraging the reduction or elimination of risky alcohol use and/or promoting effective contraceptive use among risky drinkers who could become pregnant. The current study builds on promising findings about the impact of the Centers for Disease Control and Prevention CHOICES intervention with AI/AN communities by implementing a randomized control trial of Native CHOICES, a cultural adaptation of CHOICES, with AI/AN women in a rural reservation community. METHODS: AI/AN women aged 18-44 who are at-risk for an alcohol-exposed pregnancy are being recruited. Participants are randomized in 1:1 proportion to the intervention and a services-as-usual, waitlist control condition. The Native CHOICES intervention consists of 2 motivational interviewing (MI) sessions, an elective contraception counseling session, and electronic messaging to boost the effects of MI. Data are collected at baseline and at 6 weeks, 3 months, and 6 months post-baseline. Those assigned to the control group are eligible to enroll in Native CHOICES following the completion of the 6 months post-baseline data collection. In addition to testing intervention effectiveness, the study is designed to yield a comprehensive economic evaluation, which will provide important information regarding the financial feasibility and sustainability of Native CHOICES for healthcare systems serving AI/ANs.

Emergency department utilization among individuals with idiopathic intracranial hypertension.

PURPOSE: Idiopathic intracranial hypertension (IIH) can be a debilitating disorder that is difficult to identify and treat. Failure to adequately manage IIH symptoms may force patients to present at emergency departments (EDs) seeking symptom relief. The purpose of this paper is to empirically characterize ED use by previously diagnosed IIH patients. DESIGN/METHODOLOGY/APPROACH: Patients diagnosed with IIH, and who registered with the Intracranial Hypertension Registry by 2014, were solicited for study inclusion. A survey was designed to elicit ED use during the period 2010-2012. Information on demographic and socioeconomic characteristics, IIH signs and symptoms, time since diagnosis, perspectives of ED use and quality of life was collected. Quality of life was assessed using an adaptation of the Migraine-Specific Quality of Life Questionnaire. Data were analyzed using descriptive statistics and nonparametric hypothesis tests. FINDINGS: In total, 39 percent of IIH patients used emergency services over the study period; those that did used the services intensely. These patients were more likely to be non-white, live in households making less than $25,000 annually, have public insurance and have received a diversional shunt procedure. Patients who used the ED were less likely to live in households making $100,000, or more, annually and have private insurance. Participants who used the ED had significantly lower quality-of-life scores, were younger and had been diagnosed with IIH for less time. ORIGINALITY/VALUE: ED staff and outside physicians can utilize the information contained in this study to more effectively recognize the unique circumstances of IIH patients who present at EDs.

The "Real" Number of Washington State Adolescents Using Marijuana, and Why: A Misclassification Analysis.

BACKGROUND: Although causality is difficult to establish, the regular use of marijuana has been associated with many adverse physiological and sociological consequences. There is considerable concern regarding marijuana use among adolescents, as the likelihood of adverse consequences increases significantly for this age group. The most comprehensive data for identifying risk factors for adolescent marijuana use is typically self-report, which may be over- or under-reported for a variety of reasons, including stigmatization, peer-pressure, or fear of being discovered. OBJECTIVES: To identify the prevalence of adolescent marijuana use in Washington State, and the associated risk and protective factors, while controlling for and estimating the extent of misreporting, and its determinants. METHOD: Data came from the 2014 Washington State Healthy Youth Survey. We accounted for missingness using chained multivariate imputation equations, resulting in 33,320 complete observations. Our model was estimated using a maximum likelihood multiple regression designed to control for systematic misclassification in binary dependent variables. RESULTS: Approximately 12% of Washington adolescents claimed to have used marijuana in the past 30 days. Our estimates indicate this figure is likely closer to 18%. Determinants of use included use of other substances, gender, age, and measures of deviant social influences, personality/attitude, school and family bonds, bullying, and acquisition ease. Determinants of misreporting included use of other substances, gender, parental education, and family bonds. CONCLUSIONS: Failing to control for misreporting considerably underestimates the prevalence of marijuana use among adolescents. Our model allows us to better identify at-risk adolescents and inform focused prevention efforts.

Recreational marijuana legalization and college student use: Early evidence.

We analyze marijuana use by college undergraduates before and after legalization of recreational marijuana. Using survey data from the National College Health Assessment, we show that students at Washington State University experienced a significant increase in marijuana use after legalization. This increase is larger than would be predicted by national trends. The change is strongest among females, Black students, and Hispanic students. The increase for underage students is as much as for legal-age students. We find no corresponding changes in the consumption of tobacco, alcohol, or other drugs.

SYSTEMATICALLY MISCLASSIFIED BINARY DEPENDENT VARIABLES.

When a binary dependent variable is misclassified, that is, recorded in the category other than where it really belongs, probit and logit estimates are biased and inconsistent. In some cases the probability of misclassification may vary systematically with covariates, and thus be endogenous. In this paper we develop an estimation approach that corrects for endogenous misclassification, validate our approach using a simulation study, and apply it to the analysis of a treatment program designed to improve family dynamics. Our results show that endogenous misclassification could lead to potentially incorrect conclusions unless corrected using an appropriate technique.

The Pot Calling the Kettle Black? A Comparison of Measures of Current Tobacco Use.

Researchers often use the discrepancy between self-reported and biochemically assessed active smoking status to argue that self-reported smoking status is not reliable, ignoring the limitations of biochemically assessed measures and treating it as the gold standard in their comparisons. Here, we employ econometric techniques to compare the accuracy of self-reported and biochemically assessed current tobacco use, taking into account measurement errors with both methods. Our approach allows estimating and comparing the sensitivity and specificity of each measure without directly observing true smoking status. The results, robust to several alternative specifications, suggest that there is no clear reason to think that one measure dominates the other in accuracy.

Opioid misuse among adolescents: new evidence from a misclassification analysis.

BACKGROUND: Non-medical prescription-opioid (NMPO) use has been declared a national epidemic in the US. Opioid misuse is associated with substantial physiological, psychological, and concomitant economic implications. NMPO use among adolescents warrants special attention given its prevalence and the high risk of addiction. OBJECTIVES: Our objectives were to: (a) identify factors associated with adolescent NMPO use after controlling for misclassification, while simultaneously identifying characteristics that affected the likelihood of misreporting use; and (b) identify factors associated with an individual misusing their own versus a diverted prescription, and the likelihood that the prescription source was misreported. METHODS: Data come from the Washington State Healthy Youth Survey. A maximum likelihood estimation technique for systematically misclassified binary-dependent variables was utilized. Covariates were chosen to represent influential factors identified in the theoretical adolescent development literature. RESULTS: An estimated 35 % of respondents who stated that they had never misused prescription opioids most likely had. An estimated 17 % of those who admitted to NMPO use claimed to have misused a diverted prescription, but most likely misused their own. Various demographic, school, neighborhood, family, substance-use, personality/attitude, and social factors were identified as potential predictors of adolescent NMPO use, opioid-prescription source, and misclassification of responses to each outcome. CONCLUSIONS: The finding that a self-reported survey failed to identify over one-third of individuals at risk for NMPO use is concerning, as is the finding that approximately 17 % of those who admitted to NMPO use may have misstated their prescription-opioid source. The findings presented here are critical to focus prevention efforts, especially for identifying at-risk youths who may misrepresent their use.

'Behold, a virgin is with HIV!' misreporting sexual behavior among infected adolescents.

In four Southern African countries where the HIV prevalence rate is among the highest in the world, 46.4% of a sample of female adolescents infected with HIV report having never engaged in sex. This would indicate either the dominance of non-sexual modes of HIV transmission or rampant misreporting of sexual behavior in the sample. We propose a method to estimate the extent of misreporting and calculate that the true percentages of virgins among the sample of HIV-infected adolescent women is 32.1%. After accounting for misreporting, the contribution of sexual modes of HIV transmission is projected as 50.4%, compared with an estimate of 35.5% if we assume no misreporting.

Selection effects and prevention program outcomes.

A primary goal of the paper is to provide an example of an evaluation design and analytic method that can be used to strengthen causal inference in nonexperimental prevention research. We used this method in a nonexperimental multisite study to evaluate short-term outcomes of a preventive intervention, and we accounted for effects of two types of selection bias: self-selection into the program and differential dropout. To provide context for our analytic approach, we present an overview of the counterfactual model (also known as Rubin's causal model or the potential outcomes model) and several methods derived from that model, including propensity score matching, the Heckman two-step approach, and full information maximum likelihood based on a bivariate probit model and its trivariate generalization. We provide an example using evaluation data from a community-based family intervention and a nonexperimental control group constructed from the Washington State biennial Healthy Youth Survey (HYS) risk behavior data (HYS n = 68,846; intervention n = 1,502). We identified significant effects of participant, program, and community attributes in self-selection into the program and program completion. Identification of specific selection effects is useful for developing recruitment and retention strategies, and failure to identify selection may lead to inaccurate estimation of outcomes and their public health impact. Counterfactual models allow us to evaluate interventions in uncontrolled settings and still maintain some confidence in the internal validity of our inferences; their application holds great promise for the field of prevention science as we scale up to community dissemination of preventive interventions.

Participation in Universal Prevention Programs.

We analyze family decisions to participate in community-based universal substance-abuse prevention programs through the framework of expected utility theory. Family functioning, which has been shown to be a good indicator of child risk for substance abuse, provides a useful reference point for family decision making. Our results show that well-functioning families (with children at low risk for substance use) should have the lowest incentive to participate, but that high-risk families may also opt out of prevention programs. For programs that are most effective for high-risk youth, this could be a problem. Using data from the Strengthening Families Program and the Washington Healthy Youth Survey, we empirically test the implications of our model and find that at least for one measure of family functioning those families with children most likely to be at risk for substance use are opting out of the program.

Measuring shared inefficiency between hospital cost centers.

In this article, a combination of data envelopment analysis, spreadsheet modeling and regression techniques is applied to a panel of nonprofit Washington State hospitals in an effort to determine whether (and if so, to what extent) inefficiency in one hospital cost center is shared with inefficiency in other cost centers. The findings suggest that a significant amount of inefficiency is shared across hospital cost centers. The authors further determine that certain cost centers contribute more to the overall performance of a given hospital than others. As such, managerial decisions and government policies designed to enhance hospital efficiency should be implemented differently, depending on the characteristics of the hospital in question.

Measuring bias in self-reported data.

Response bias shows up in many fields of behavioural and healthcare research where self-reported data are used. We demonstrate how to use stochastic frontier estimation (SFE) to identify response bias and its covariates. In our application to a family intervention, we examine the effects of participant demographics on response bias before and after participation; gender and race/ethnicity are related to magnitude of bias and to changes in bias across time, and bias is lower at post-test than at pre-test. We discuss how SFE may be used to address the problem of 'response shift bias' - that is, a shift in metric from before to after an intervention which is caused by the intervention itself and may lead to underestimates of programme effects.

Detecting selection effects in community implementations of family-based substance abuse prevention programs.

To calculate valid estimates of the costs and benefits of substance abuse prevention programs, selection effects must be identified and corrected. A supplemental comparison sample is typically used for this purpose, but in community-based program implementations, such a sample is often not available. We present an evaluation design and analytic approach that can be used in program evaluations of real-world implementations to identify selection effects, which in turn can help inform recruitment strategies, pinpoint possible selection influences on measured program outcomes, and refine estimates of program costs and benefits. We illustrate our approach with data from a multisite implementation of a popular substance abuse prevention program. Our results indicate that the program's participants differed significantly from the population at large.